Transcript QIO-HealthInsight Branding Template

Care Transitions
Learning and Action
Network
Today’s Agenda
• Welcome and Readmission Data Discussion
– Rebecca Durham, HealthInsight
1:20 - 1:35 p.m.
• Why We are interested in Readmissions
– Michelle Carlson, HealthInsight
• Effective Communication Tools
1:35 - 2:00 p.m.
2:00 - 2:20 p.m.
– Michelle Carlson/Rebecca Durham
Group Discussion
2:20 - 2:50 p.m.
– Everyone
Wrap up and Evaluations
2:50- 3:00 p.m.
What are our aims?
• Our overall goal is to reduce 30-day hospital readmissions for
Medicare FFS patients in Utah by 20% by July 31, 2014.
Nationwide, about 1 in 5 Medicare beneficiaries are
readmitted to the hospital within 30 days of discharge (Jencks
et al., 2009).
• Our objectives are to engage with care providers and
communities around the state to examine the root causes of
30-day readmissions and implement evidence-based
interventions to address these causes…
• So that Medicare beneficiaries have improved health and
spend more time at home, instead of in the hospital.
How are we doing?
• In general, Utah has one of the lowest rates of
hospital readmissions for people with Medicare in
the country:
Utah
US
Medical Discharges
13.1%
16.1%
Surgical Discharges
9.8%
12.7%
CHF Discharges
15.5%
21.2%
AMI Discharges
11.5%
18.5%
Pneumonia Discharges
11.2%
15.2%
Hip Fracture Discharges
8.6%
14.5%
….But that is no reason to be complacent!
Source: Dartmouth Atlas of Healthcare, analysis of 2009 adjusted data for US Medicare population
Annual All-Cause 30-Day
Readmission Rates
• Utah, 2011
– Hospital level: 13.4%
• Range: 5.0% - 16.7%*
• Clearly, there is a lot of variation amongst
hospitals and some are having great success
with rates below 10%!
*Excluding hospitals with <100 denominator
Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
So who gets readmitted?
Readmission Rates per 1,000 Beneficiaries for Selected Conditions,
Utah 2009-2011
18
16
14
12
AMI
COPD
10
Chronic Renal Failure
CHF
8
Diabetes
6
Pneumonia
4
2
0
3/31/2010
6/30/2010
9/30/2010
12/31/2010
3/31/2011
6/30/2011
9/30/2011
12/31/2011
Source: HealthInsight analysis based on Medicare FFS claims for the period of 4/1/2009-12/31/2011.
Date axis reflects year end date.
Where did they go when they left
the hospital?
• Percentage of 30-day readmissions by status at index
admission discharge
Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
How can data help us ?
identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009 .
How can data help us
identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009 .
How can data help us
identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009 .
How can data help us
identify potential partners?
Source: Analysis based on Medicare FFS claims for 2009 .
How can data help us
with root causes?
• One driver of 30-day readmission rates is lack
of timely follow up with outpatient care after
discharge from hospital.
• In Utah in 2011,
– 48.5% of patients who were readmitted to the
hospital within 30 days were readmitted within 10
days of discharge
– 37.7% of patients who were readmitted to the
hospital within 30 days were readmitted within 7
days of discharge
Source: HealthInsight analysis based on Medicare FFS claims for the period of 1/1/2011-12/31/2011.
We are here to help!
• Data and the information they generate are
extremely useful for finding patterns and examining
trends, and we have data that can help light the
path.
• But we still need YOU to walk the path with us and
help us learn what we cannot from data alone.
Thank you!
Rebecca Durham
[email protected]
801-892-6620
Community-Based Care
Coordination
339 Days in the Life of Mrs. B
A Medicare Beneficiary
Mrs. B
Newly Established Patient with
Internal Medicine Physician
• A regular source of care
• Initial visit - DM, HTN, osteoporosis and
hypothyroidism
o DM poorly controlled, early numbness
• Scheduled bi-monthly visits until DM
controlled
Day 15
Status:
Fully functional, Helps with grandkids
Takes care of her husband
Providers:
Internist
Ophthalmologist (?)
Medications:
2 HTN each 1x/d, 2 DM each 2x/d
1 osteoporosis once weekly
1 hypothyroidism 1x/d, Eye drops
Payments:
$180.00
Daughter:
Dinner weekly
Worries about Dad
Day 60
Day 60
• Lacerations,
abrasions, and
contusions
• Sutures, basic wound
care
• Discharged to home
Day 68
Status:
Homebound receiving Home Health
Not feeling well
Providers:
Internist
ED doctor
Medications:
2 HTN each 1x/d, 2 DM each 2x/d
1 osteoporosis once weekly
1 hypothyroidism 1x/d, Pain meds – every 46 hrs.
Payments:
$3,256 – ED, $476 – HHA, $99 – PCP $4,011
Daughter:
Daily visits, doing the shopping
Transportation to appts.
Worried about Dad
Physical therapist
Occupational therapist
Day 69
•
•
•
•
•
•
•
Staph infection
Dehydration
Atrial Fibrillation
Acute Renal Failure
CHF
Pneumonia
DM – not mentioned
Day 82
Status:
Providers:
Discharge to SNF – ADLs, Depressed
Internist
ED doctor
Hospitalist
Cardiologist
HH Physical therapist
HH Occ therapist
Hospital PT
Medications:
2 HTN each 1x/d, 2 DM each 2x/d
2 HF meds – each 1x/d, Antidepressant –
1x/d, 1 osteoporosis once weekly
1 hypothyroidism 1x/d, Pain meds – every 46 hrs, 2 antibiotics – 1x/d and 2x/d
Antidepressant – 1x/d
Payment:
$48,009
$52,020
Days 82-182: SNF
•
•
•
•
•
•
Daily PT
Excellent wound care
Has visit from PCP
Diabetes control improved
Neuropathy continues
Ambulation potential not returned to
baseline
Day 182
Status:
Providers:
Medications:
To Home
Internist
ED doctor
Hospitalist
Cardiologist
HH Physical therapist
HH Occ therapist
Hospital PT
2 HTN each 1x/d, 2 DM each 2x/d
2 HTN each 1x/d, 2 DM each 2x/d
2 HF meds – each 1x/d, Antidepressant –
1x/d, 1 osteoporosis once weekly
1 hypothyroidism 1x/d, Pain meds – every 46 hrs, 2 antibiotics – 1x/d and 2x/d
Antidepressant – 1x/d
Day 182 (Continued)
Payment:
$34,495 – SNF
$99 – PCP
Daughter:
Stressed out
Daily visits to Dad at home
Daily visits to SNF
Feels guilty about noticing that the SNF
made her life easier
Committed to getting her mother “back to
normal”
Thinking about working part time
Budgeting for college educations
$86,614
Day 183
• Home
• Nauseated/poor appetite
• Unsure what to eat – doesn’t feel like
eating anyway
• Can’t find her teeth
• Husband vague, needs help with basic
decisions
• Daughter comes 2x/d; Working parttime intends to call PCP to schedule
HH again
Day 184
•
•
•
•
Dehydration
CHF
Atrial Fib
DM
Day 190
Status:
Providers:
Medications:
Discharge to SNF
Internist
ED doctor
Hospitalist (2)
Cardiologist
SNFist
HH PT
HH OT
Hospital PT
SNF PT (2)
SNF OT (2)
2 HTN each 1x/d
2 DM each 2x/d
2 HF meds – each 1x/d
1 osteoporosis once weekly
1 hypothyroidism 1x/d
1 antidepressant 1x/d
Day 190 (Continued)
Payment:
$24,281 - hospital $110,895
Daughter:
Stressed out
Daily visits to Dad at home – looking for day
care program
Feels guilty about readmission
Committed to getting her mother “back to
normal”
Has begun working part time
Budgeting for college educations
Days 191-337: SNF
• Intensive PT/ gait training, self-management
training
• Daughter visits often but is unable to make it
daily
• Dad in daily day care – daughter considering
NH
• Progressive renal failure/ heart failure
• Intermittent atrial fibrillation
Day 338
•
•
•
•
•
Readmission
Acute renal failure
Decompensated CHF
Acute respiratory failure
Acidosis
Day 339
Status:
Providers:
Deceased
Internist
ED doctor
Hospitalist (2)
Cardiologist
SNFist
HH PT
HH OT
Hospital PT
SNF PT (2)
SNF OT (2)
Payments:
$18,393 – hospital, SNF - $50,370 $179,658
Daughter:
Grieving
Worried about Dad
Worried about personal finances
What’s Wrong?
Conceptually…
• Reactive care
– Chronic disease care in acute care settings
• Diagnosis-specific thinking
– ‘Guideline-Driven Care’
• No integration of Mrs. B nor her daughter
• Multiple Transitions of Care – No coordination
What we Really Need is Intentionally Designed Care
that meets the needs of patients and families..
Cause of Readmission = Poor or
Non-existent Transitions of Care
• Medication Problems
o Improperly managed by the HC team
o Patient non-adherence through poor
understanding
• Lack of reliable follow-up care
o Receiving providers unaware
• Poor patient engagement
o Symptom worsening
Solutions
• Medication Problems
o
Improperly managed
by the HC team
o
Patient nonadherence through
poor understanding
• Lack of reliable follow-up
care
o
Receiving providers
unaware
• Poor patient engagement
o
Symptom worsening
1. Patient
engagement and
healthcare
coaching
2. Handover
management
3. Information
transfer
Patient-Centered
Plan of Care
Personal Health Record
*Medication List/Reconciliation
*Warning Signs
*Allergies
*List of physicians
Intervention Packages
Intervention Reference
Care Transitions
InterventionSM
Transitional Care
Nursing
CMS Discharge
Checklist
Main Tools
Driver
Addressed
HM
(2)
PE
(1)
IT
(3)
www.caretransitions.org
Coaches, personal health record,
medication discrepancy tool
?
XXX
X
www.transitionalcare.info/
index.html0
Risk assessment , nursing training
materials
?
XXX
XX
Patient and family checklist of important
items to address before discharge
Screening/assessment, provider discharge
checklist, transition record, teach-back
instructions, data collection and tracking
?
XXX
X
www.medicare.gov
BOOST
www.hospitalmedicine.org/
ResourceRoomRedesign
Best Practices
Intervention
Package (BPIP)
www.homehealthquaqlity.o
Comprehensive manual for HHA process
rg/hh/ed_resources/interven
improvement includes CTI teaching
tionpackages/default.aspx
XX
INTERACT
Interact.geriu.org
Communication tools, clinical care paths,
advanced care planning
XX
(Re)Admission assessment, teach-back,
pt and family communication, scheduled
f/u
XXX
Nurse discharge advocate, pharmacy f/u
medication teaching, PCP f/u booklet
XXX
Transforming Care
at the Bedside
(TCAB)
Re-Engineered
Discharge (RED)
www.ihi.org/IHI/Programs/
StrategicInitiatives/Transfor
mingCareAt
TheBedside.htm
www.bu.edu/fammed/proje
ctred/index.gtml
XXX
XX
XX
XX
XX
XX
X
XX
Interact II
Early Warning Tool
“Stop and Watch”
Purpose: To identify a Change in Condition
with a Patient or Resident
►Can be used by ANY staff or person who
has direct patient/resident contact
►Must be reported to charge nurse during
shift of occurrence or sooner if indicated.
SBAR
• Situation
• Background
• Assessment
• Request/Recommendation
*Originated in the US Navy Nuclear
Submarine Service
Purpose: To improve communication between
Nurses and MD/NP/PA (PCP)
SBAR
• Used effectively across healthcare settings
to improve communication
• A great tool for new nurses to help enhance
their assessment skills
• Provides standardization across settings
• Relatively easy to implement- back page is
a blank progress note to reduce duplication.
LINC & Infection Control (IC)
•LINC= Linking Information Necessary for Care
- A collaborative effort by multiple stakeholders to
increase communication upon transfers
- Currently with UHIN working on digitizing
•Infection Control= Transfer form intended to
accompany any resident/patient with an infectious
condition.
- Contains definitions & standard precautions
Questions
• What processes can be improved in my
setting by implementing the Interact II,
S-BAR and/or the Stop and Watch tool?
• What would be the first steps in
implementing these tools?
Ideas on how to use these
tools in your settings ?
Please help us to improve our events.
Complete your evaluation!
• The evaluation has two pages:
– The first page is completed anonymously and tells us how
satisfied you are with the content and presentations you
heard today. You do not need to put your name on this
evaluation. Comments are welcome!
– The second page tells us how you plan to implement what
you have learned today and how HealthInsight can assist
you. Completing this page is necessary for you to receive
CME or an attendance certificate. Please be sure to put
your name and contact information at the top of this
page!
• Please separate the two pages after you have filled
them out and turn them in to HealthInsight staff.
Questions?
Michelle Carlson
[email protected]
801-892-6646
Rebecca Durham
[email protected]
801-892-6620